An international, consensus-derived Core Outcome Set for Cardiac Arrest effectiveness trials: the COSCA initiative

Telephone-based evaluation of cognitive impairment and mood disorders in cardiac arrest survivors with good neurologic outcomes: a retrospective cohort study

This study determined the occurrence of cognitive impairment and mood disorders in out-of-hospital cardiac arrest (OHCA) survivors with good neurologic outcomes. We performed a retrospective, cross-sectional, single-center study with a total of 97 patients. We evaluated cognitive dysfunction via the Montreal Cognitive Assessment and Alzheimer's disease-8 mood disorders via the Patient Health Questionnaire-9 and the Hospital Anxiety and Depression Scale. We measured quality of life with the European Quality of Life 5-Dimension 5-Levels questionnaire. Cognitive impairment and mood disorders were common among patients with good neurologic recovery. There were 23 patients who experienced cognitive impairments (23.7%) and 28 who suffered from mood disorders (28.9%). Age (adjusted OR 1.07, 95% CI 1.02-1.12), mood disorders (adjusted OR 22.80, 95% CI 4.84-107.49) and hospital length of stay (adjusted OR 1.05, 95% CI 1.02-1.09) were independent risk factors for cognitive impairment. The occurrence of cognitive impairments (adjusted OR 9.94, 95% CI 2.83-35.97) and non-cardiac causes of cardiac arrest (adjusted OR 11.51, 95% CI 3.15-42.15) were risk factors for mood disorders. Quality of life was significantly lower in the OHCA survivors with each disorder than the healthy individuals. Routine screening and intervention are needed for OHCA survivors.

Standardized Definitions for Cardiogenic Shock Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium (SHARC)

The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies, industry, and payers, convened to develop pragmatic consensus definitions useful for the evaluation of clinical trials enrolling patients with cardiogenic shock, including trials evaluating mechanical circulatory support devices. Several in-person and virtual meetings were convened between 2020 and 2022 to discuss the need for developing the standardized definitions required for evaluation of mechanical circulatory support devices in clinical trials for cardiogenic shock patients. The expert panel identified key concepts and topics by performing literature reviews, including previous clinical trials, while recognizing current challenges and the need to advance evidence-based practice and statistical analysis to support future clinical trials. For each category, a lead (primary) author was assigned to perform a literature search and draft a proposed definition, which was presented to the subgroup. These definitions were further modified after feedback from the expert panel meetings until a consensus was reached. This manuscript summarizes the expert panel recommendations focused on outcome definitions, including efficacy and safety.

Harrison D, Hossain A, Lall R, Mason J, Nolan JP, Nwankwo H, Perkins GD, Samuel K, Schofield B, Soar J, Starr K, Thomas M, Voss S, Benger JR. Randomised trial of the clinical and cost effectiveness of a supraglottic airway device compared with tracheal intubation for in-hospital cardiac arrest (AIRWAYS-3): Protocol, design and implementation

Survival from in-hospital cardiac arrest is approximately 18%, but for patients who require advanced airway management survival is lower. Those who do survive are often left with significant disability. Traditionally, resuscitation of cardiac arrest patients has included tracheal intubation, however insertion of a supraglottic airway has gained popularity as an alternative approach to advanced airway management. Evidence from out-of-hospital cardiac arrest suggests no significant differences in mortality or morbidity between these two approaches, but there is no randomised evidence for airway management during in-hospital cardiac arrest. The aim of the AIRWAYS-3 randomised trial, described in this protocol paper, is to determine the clinical and cost effectiveness of a supraglottic airway versus tracheal intubation during in-hospital cardiac arrest. Patients will be allocated randomly to receive either a supraglottic airway or tracheal intubation as the initial advanced airway management. We will also estimate the relative cost-effectiveness of these two approaches. The primary outcome is functional status, measured using the modified Rankin Scale at hospital discharge or 30 days post-randomisation, whichever occurs first. AIRWAYS-3 presents ethical challenges regarding patient consent and data collection. These include the enrolment of unconscious patients without prior consent in a way that avoids methodological bias. Other complexities include the requirement to randomise patients efficiently during a time-critical cardiac arrest. Many of these challenges are encountered in other emergency care research; we discuss our approaches to addressing them. Trial registration: ISRCTN17720457. Prospectively registered on 29/07/2022.

Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest

BACKGROUND

Evidence to support the choice of blood-pressure targets for the treatment of comatose survivors of out-of-hospital cardiac arrest who are receiving intensive care is limited.

METHODS

In a double-blind, randomized trial with a 2-by-2 factorial design, we evaluated a mean arterial blood-pressure target of 63 mm Hg as compared with 77 mm Hg in comatose adults who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause; patients were also assigned to one of two oxygen targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category (CPC) of 3 or 4 within 90 days (range, 0 to 5, with higher categories indicating more severe disability; a category of 3 or 4 indicates severe disability or coma). Secondary outcomes included neuron-specific enolase levels at 48 hours, death from any cause, scores on the Montreal Cognitive Assessment (range, 0 to 30, with higher scores indicating better cognitive ability) and the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at 3 months, and the CPC at 3 months.

RESULTS

A total of 789 patients were included in the analysis (393 in the high-target group and 396 in the low-target group). A primary-outcome event occurred in 133 patients (34%) in the high-target group and in 127 patients (32%) in the low-target group (hazard ratio, 1.08; 95% confidence interval [CI], 0.84 to 1.37; P = 0.56). At 90 days, 122 patients (31%) in the high-target group and 114 patients (29%) in the low-target group had died (hazard ratio, 1.13; 95% CI, 0.88 to 1.46). The median CPC was 1 (interquartile range, 1 to 5) in both the high-target group and the low-target group; the corresponding median modified Rankin scale scores were 1 (interquartile range, 0 to 6) and 1 (interquartile range, 0 to 6), and the corresponding median Montreal Cognitive Assessment scores were 27 (interquartile range, 24 to 29) and 26 (interquartile range, 24 to 29). The median neuron-specific enolase level at 48 hours was also similar in the two groups. The percentages of patients with adverse events did not differ significantly between the groups.

CONCLUSIONS

Targeting a mean arterial blood pressure of 77 mm Hg or 63 mm Hg in patients who had been resuscitated from cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.).

Establishment of a core outcome set for burn care research: development and international consensus

Objective

To develop a core outcome set for international burn research.

Design

Development and international consensus, from April 2017 to November 2019.

Methods

Candidate outcomes were identified from systematic reviews and stakeholder interviews. Through a Delphi survey, international clinicians, researchers, and UK patients prioritised outcomes. Anonymised feedback aimed to achieve consensus. Pre-defined criteria for retaining outcomes were agreed. A consensus meeting with voting was held to finalise the core outcome set.

Results

Data source examination identified 1021 unique outcomes grouped into 88 candidate outcomes. Stakeholders in round 1 of the survey, included 668 health professionals from 77 countries (18% from low or low middle income countries) and 126 UK patients or carers. After round 1, one outcome was discarded, and 13 new outcomes added. After round 2, 69 items were discarded, leaving 31 outcomes for the consensus meeting. Outcome merging and voting, in two rounds, with prespecified thresholds agreed seven core outcomes: death, specified complications, ability to do daily tasks, wound healing, neuropathic pain and itch, psychological wellbeing, and return to school or work.

Conclusions

This core outcome set caters for global burn research, and future trials are recommended to include measures of these outcomes.

Co-producing a multi-stakeholder Core Outcome Set for distal Tibia and Ankle fractures (COSTA): a study protocol

BACKGROUND

Ankle fracture is a common injury with a strong evidence base focused on effectiveness of treatments. However, there are no reporting guidelines on distal tibia and ankle fractures. This has led to heterogeneity in outcome reporting and consequently, restricted the contribution of evidence syntheses. Over the past decade, core outcome sets have been developed to address this issue and are available for several common fractures, including those of the hip, distal radius, and open tibial fractures. This protocol describes the process to co-produce-with patient partners and other key stakeholders-a multi-stakeholder derived Core Outcome Set for distal Tibia and Ankle fractures (COSTA). The scope of COSTA will be for clinical trials.

METHODS

The study will have five-stages which will include the following: (i) systematic reviews of existing qualitative studies and outcome reporting in randomised controlled trial studies to inform a developing list of potential outcome domains; (ii) qualitative interviews (including secondary data) and focus groups with patients and healthcare professionals to explore the impact of ankle fracture and the outcomes that really matter; (iii) generation of meaningful outcome statements with the study team, international advisory group and patient partners; (iv) a multi-round, international e-Delphi study to achieve consensus on the core domain set; and (v) an evidence-based consensus on a core measurement set will be achieved through a structured group consensus meeting, recommending best assessment approaches for each of the domains in the core domain set.

DISCUSSION

Development of COSTA will provide internationally endorsed outcome assessment guidance for clinical trials for distal tibia and ankle fractures. This will enhance comparative reviews of interventions, potentially reducing reporting bias and research waste.

A Core Outcome Set for Research in Patients on Extracorporeal Membrane Oxygenation

OBJECTIVES

A core set of outcomes have been identified and published, which are essential to include in all clinical research evaluating the use of extracorporeal membrane oxygenation in critically ill patients, particularly regarding safety and adverse events. The purpose of this international modified Delphi study was to determine which measurement tools and the timing of measurement should be selected for the core outcome set for research evaluating patients receiving extracorporeal membrane oxygenation.

DESIGN

This was a two-round international, multidisciplinary web-based, modified Delphi study.

PATIENTS

Participants were identified from the International Extracorporeal Membrane Oxygenation Network and the Extracorporeal Life Support Organization, including consumers, multidisciplinary clinicians, researchers and industry partners.

MEASUREMENTS

Measurement tools and the timing of measurement were identified from a systematic review of the literature and clinical trials registrations. The primary outcome was the percentage of respondents who completed each survey and indicated that a measurement tool as well as the timing of the measurement should "always" be included in a core outcome set.

MAIN RESULTS

Participant response rates were 46 of 65 (71%) and 40 of 46 (87%) for rounds one and two, respectively, with participants representing, researchers, consumers, and industry partners from 15 countries over five continents. Seven measurement tools were identified for the core outcome set of patients on extracorporeal membrane oxygenation.

CONCLUSIONS

This study has identified appropriate measurement instruments and the timing of measurement to include in the core outcome set for research evaluating patients receiving extracorporeal membrane oxygenation. This was an important final step to standardize and synthesize research efforts internationally.

Quality Assessment of the Literature on Quality Improvement in PICUs: A Systematic Review

OBJECTIVES

To synthesize the literature describing quality improvement in PICUs and to appraise the quality of extant research.

DATA SOURCES

We searched the PubMed, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials databases between May and June 2020.

STUDY SELECTION

Peer-reviewed articles in English that report quality improvement interventions in PICUs were included. Titles and abstracts were screened, and articles were reviewed to determine whether they met quality improvement criteria.

DATA EXTRACTION

Data were abstracted using a structured template. The quality of the included articles was assessed using the Quality Improvement Minimum Quality Criteria Set and scored on a scale of 0-16.

DATA SYNTHESIS

Of the 2,449 articles identified, 158 were included in the analysis. The most common targets of quality improvement interventions were healthcare-associated infections (n = 17, 10.8%), handoffs (n = 15, 9.5%), rounds (n = 13, 8.2%), sedation/pain/delirium (n = 13, 8.2%), medication safety (n = 11, 7.0%), and unplanned extubation (n = 9, 5.7%). Of the six domains of healthcare quality described by the Institute of Medicine, patient-centeredness and timeliness were infrequently addressed, and none of the studies addressed equity. The median quality score based on the Quality Improvement Minimum Quality Criteria Set was 11.0 (25-75th interquartile range, 9.0-13.0). Although the quantity and quality of articles have been increasing, only 17% of the studies were deemed "high quality," having a score between 14 and 16. Only eight articles (5%) cited Standards for QUality Improvement Reporting Excellence guidelines for reporting quality improvement works.

CONCLUSIONS

The number of publications, including high-quality publications, on quality improvement interventions in PICUs has been increasing. However, low-quality articles continue to be published, even in recent years. Therefore, there is room for improvement in the quality of reporting.

The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review

Aim

We aimed to collect the available evidence on outcome regarding survival and quality of life after CPR following both IHCA and OHCA in the older population.

Findings

Hospital survival rates following IHCA and OHCA in the older population improved in the recent decade, though do not exceed 28.5% and 11.1%, respectively. The effect of age on outcome remains controversial and age should not be used as the sole decision criterium whether to initiate CPR.

Message

Future research should study frailty and resilience as an independent predictor regardless of age, and add broader, extensive QoL measures as outcome variables.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00454-y.

Purpose

We aimed to collect the available evidence on outcome regarding survival and quality of life after cardiopulmonary resuscitation (CPR) following both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) in the older population.

Methods

A scoping review was performed studying published reviews after 2008, focusing on outcome of CPR in patients aged ≥ 70 years following IHCA and OHCA. In addition, 11 (IHCA) and 19 (OHCA) eligible studies published after the 2 included reviews were analyzed regarding: return of spontaneous circulation, survival until hospital discharge, long-term survival, neurological outcome, discharge location or other measurements for quality of life (QoL).

Results

The survival until hospital discharge ranged between 11.6 and 28.5% for IHCA and 0–11.1% for OHCA, and declined with increasing age. The same trend was seen regarding 1-year survival rates with 5.7–25.0% and 0–10% following IHCA and OHCA, respectively. A good neurological outcome defined as a Cerebral Performance Category (CPC) 1–2 was found in 11.5–23.6% (IHCA) and up to 10.5% (OHCA) of all patients. However, the proportion of CPC 1–2 among patients surviving until hospital discharge was 82–93% (IHCA) and 77–91.6% (OHCA). Few studies included other QoL measures as an outcome variable. Other risk factors aside from age were identified, including nursing home residency, comorbidity, non-shockable rhythm, non-witnessed arrest. The level of frailty was not studied as a predictor of arrest outcome in the included studies.

Conclusions

Hospital survival rates following IHCA and OHCA in the older population improved in the recent decade, though do not exceed 28.5% and 11.1%, respectively. The effect of age on outcome remains controversial and age should not be used as the sole decision criterium whether to initiate CPR. Future research should study frailty and resilience as an independent predictor regardless of age, and add broader, extensive QoL measures as outcome variables.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00454-y.

Core Outcome Measures for Research in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation for Acute Respiratory or Cardiac Failure: An International, Multidisciplinary, Modified Delphi Consensus Study

OBJECTIVES

Research evaluating outcomes in critically ill patients with acute respiratory and cardiac failure supported with extracorporeal membrane oxygenation has increased significantly. The objective was to identify a core set of outcomes that are essential to include in all clinical research evaluating the use of either venoarterial or venovenous extracorporeal membrane oxygenation in critically ill patients, particularly regarding safety and adverse events.

DESIGN

A three-round modified Delphi process.

SUBJECTS

Patients, caregivers, multidisciplinary clinicians, researchers, industry partners, and research funders were included.

SETTING

Participants represented key extracorporeal membrane oxygenation organizations, including the Extracorporeal Life Support Organization, the International Extracorporeal Membrane Oxygenation Network, clinicians from high volume extracorporeal membrane oxygenation centers, and extracorporeal membrane oxygenation researchers or former extracorporeal membrane oxygenation patients from five continents.

INTERVENTIONS

We used recommended standards for the development of a core outcome set. Outcome measures identified from systematic reviews of the literature and from qualitative studies of survivors were mapped to the domains identified by the Core Outcome Measures in Effectiveness Trials initiative separately for venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS

Participant response rates were 40 of 47 (85%), 35 of 37 (95%), and 64 of 69 (93%) for survey rounds 1, 2, and 3, respectively, with participants representing 10 different countries on five continents. After the third round survey, 8 outcome measures met consensus for both venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation.

CONCLUSIONS

This study identified core outcomes to assess in all research evaluating the use of extracorporeal membrane oxygenation, including adverse events specific to this intervention, permitting standardization of outcome reporting for the first time. Identifying appropriate measurement instruments to evaluate these outcomes is an important next step to enable synthesis of extracorporeal membrane oxygenation research.

A systematic methodological review of non-randomised interventional studies of elective ventral hernia repair: clear definitions and a standardised minimum dataset are needed

BACKGROUND

Ventral hernias (VHs) often recur after surgical repair and subsequent attempts at repair are especially challenging. Rigorous research to reduce recurrence is required but such studies must be well-designed and report representative and comprehensive outcomes.

OBJECTIVE

We aimed to assesses methodological quality of non-randomised interventional studies of VH repair by systematic review.

METHODS

We searched the indexed literature for non-randomised studies of interventions for VH repair, January 1995 to December 2017 inclusive. Each prospective study was coupled with a corresponding retrospective study using pre-specified criteria to provide matched, comparable groups. We applied a bespoke methodological tool for hernia trials by combining relevant items from existing published tools. Study introduction and rationale, design, participant inclusion criteria, reported outcomes, and statistical methods were assessed.

RESULTS

Fifty studies (17,608 patients) were identified: 25 prospective and 25 retrospective. Overall, prospective studies scored marginally higher than retrospective studies for methodological quality, median score 17 (IQR: 14-18) versus 15 (IQR 12-18), respectively. For the sub-categories investigated, prospective studies achieved higher median scores for their, 'introduction', 'study design' and 'participants'. Surprisingly, no study stated that a protocol had been written in advance. Only 18 (36%) studies defined a primary outcome, and only 2 studies (4%) described a power calculation. No study referenced a standardised definition for VH recurrence and detection methods for recurrence varied widely. Methodological quality did not improve with publication year or increasing journal impact factor.

CONCLUSION

Currently, non-randomised interventional studies of VH repair are methodologically poor. Clear outcome definitions and a standardised minimum dataset are needed.